Healthcare Provider Details

I. General information

NPI: 1689272031
Provider Name (Legal Business Name): BARBARA BARNEWOLT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 N UNIVERSITY ST
PEORIA IL
61604-1324
US

IV. Provider business mailing address

13225 N KELSTADT RD
BRIMFIELD IL
61517-9651
US

V. Phone/Fax

Practice location:
  • Phone: 855-476-5837
  • Fax: 309-280-6045
Mailing address:
  • Phone: 309-635-0621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number05136625
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: